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If I am suffering from continued anxiety after achieving sobriety, can I continue to take Ativan or similar antianxiety medication?

Anxiety, Insomnia, and Depression

The level of anxiety and insomnia that one continues to experience after successful detox can remain high for several months afterward. This is sometimes referred to by it's acronym, PAWS, for Post Acute Withdrawal Syndrome. Depression usually lifts sooner. These symptoms may be one of many reasons that the risk of relapse remains high. The use of sedative/ hypnotic agents during this period of time only prolongs the symptoms; however, the patient must be monitored and evaluated for an underlying mood or anxiety disorder that may be independent of residual withdrawal symptoms. If the symptoms persist, the likelihood of having an underlying anxiety or mood disorder increases with each passing month of sobriety. Most clinicians agree that a period of 12 months of sobriety in which one may or may not experience mood or anxiety symptoms is the best determinant of an underlying disorder independent of alcoholism; however, this does not necessarily mean that treatment of the mood disorder should be withheld for those 12 months. It will depend partly on the severity of the symptoms and the level of disability that can result from them. Depression is generally easier to treat under these circumstances, particularly because none of the medications used is addictive. If there is an underlying anxiety disorder, the next question is this: What is the most appropriate treatment?

The level of anxiety and insomnia that one continues to experience after successful detox can remain high for several months afterward. This is sometimes referred to by it's acronym, PAWS, for Post Acute Withdrawal Syndrome. Depression usually lifts sooner.

Treatment

Although psychotherapy may be the optimal treatment approach, either through groups such as AA or individual treatment, sometimes it is just not enough to manage the symptoms. The natural inclination would be to turn to an antianxiety agent that works immediately and effectively such as the benzodiazepines, which are a class of antianxiety medications known best by one of their original medications, Valium, or diazepam, and Librium, or chlordiazepoxide. These agents are used for detoxification and were discussed in Question 56. The issue of whether one can continue to take benzodiazepines for anxiety in the face of a history of alcoholism remains highly controversial. The general rule is no. The reason for this is based on their physiological effects. Benzodiazepines enhance GABA activity by making the GABA receptor more sensitive to GABA's effects. This is exactly what alcohol does to the GABA receptor. Thus, benzodiazepines, in a sense, are a substitute for alcohol. This is why they are so effective for detoxification from alcohol. For this reason, alcoholics tend to abuse these medications at greater rates than the general population. Physiological tolerance does develop from chronic use, and the risks of developing either a withdrawal delirium or withdrawal seizure are just as high. Additionally, long-term use of benzodiazepines can impair memory and cognition, as well as contribute to depression.

Long-Term Treatment with Benzodiazepines

There are instances in which patients with a history of alcoholism are maintained on benzodiazepines long term. Although there are very specific reasons for this, the use of benzodiazepines long term is a rarity. First, patients who are on benzodiazepines have a clearly documented anxiety disorder independent of their alcoholism. Second, their alcoholism is typically limited to either problem drinking or alcohol abuse but not alcohol dependence. Finally, all other medications that treat the anxiety disorder have been tried and failed for a variety of reasons. Only in this very limited instance are benzodiazepines prescribed to a former alcoholic on a long-term basis, and not without some degree of trepidation and close monitoring.

It is important to bear in mind that the evidence suggesting that benzodiazepines are highly addictive drugs is simply not there. Although it is true that drug and alcohol abusers are more likely to abuse these medications than the general population, it is not true that the general population is as susceptible to becoming addicted to benzodiazepines as they are to alcohol or other drugs of abuse. Everyone will develop tolerance and withdrawal symptoms to one degree or another with long-term use of benzodiasepines, although few will end up dependent as the DSM-IV-TR defines it. In fact, even among alcoholics, it is less common to find them using benzodiazepines at ever-increasing amounts in the same manner that they escalate their alcohol use. This is one of the primary reasons these medications remain so controversial. Those addicted to alcohol often destroy their bodies and lives in its pursuit; rarely do they destroy their bodies and lives in pursuit of a benzodiazepine. In fact, most moderate their benzodiazepine use in a manner one could only wish for in their alcohol use. For those who happen to be both alcohol and benzodiazepine dependent, benzodiazepines are rarely ever a complete substitute for the pursuit of alcohol.

If not benzodiazepines, what medication is appropriate to manage anxiety?

Unfortunately, the anxiety that often accompanies alcoholism is quite tenacious and difficult to treat, leading to rather heroic efforts on the part of physicians to try medications off-label.

 
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